Monday, October 10, 2016

Shifting Sources of Power and Equality
All animals are equal but some are more equal than others.
George Orwell,  Animal Farm
As everybody knows,  social trends shift.
These equality shifts, often decades in the making, include:
·         The shift from masculine to feminine.  Women now dictate power shifts – in politics, in boardrooms, in the professions.  We shall soon have a woman president, more corporate women CEOs, more women lawyers and doctors and other professionals. 

·         The shift from traditional conservative values to more progressive secular values.  We see this everywhere, from attitudes towards gender equality, to same sex and cross-racial marriages, to more permissiveness towards teens,  to more acceptance of marijuana use.

·         The shift from nationalism to globalism.  Immigration across borders is growing,  more international trade is the norm,    more acceptance of other cultures is said to be desirable,  international travel and education is on the rise.

·         The shift from straight unadorned talk to political correctness. Politically correct speech is telling people what you think  they want to hear without offending anybody in a totally tolerant world.

·         The shift from individualism to corporate and large group activities.   You see this particularly in medicine.  The social media  ostensibly has fostered individual ism,  but in reality,  Facebook, Twitter, and iphones  and  the like are social collectivism activities and account for the world’s fastest growing international corporations.

·         The shift from privacy to transparency.    With emails and algorithms and open computer systems  and electronic health records,  credit cards,  and big data tracking,  nothing is private or confident anymore.

·         The shift from human decision making to machine decision making.    The use of machine learning and algorithms  over humans to solve and monitor complex problems.
Some of us yearn for the good old days when men were men, and women were women, and you could tell the difference; when you knew where you stood  based on values embedded over generations;   when you accepted the belief that it was the right thing to be patriotic and that your  country stood for what was good and noble;  when you acted on the basis of what was good for you was good for society and did not need outside management; when individual privacy  and confidentiality  were respected; when you didn’t need an algorithm to tell you how to act or think;  when you said what you meant and meant what you said.

Ah, yes, those were the days.











Second Presidential Dabate Transcript – ObamaCare Comments


Cooper: Ken Karpowitz has a question.

Karpowicz: The Affordable Care Act known as Obamacare, it is not affordable. Premiums have gone up, deductibles have gone up, copays has gone up, prescriptions have gone up and the coverage has gone down. What will you do to bring the cost down and make coverage better?

Cooper: That first one goes to secretary Clinton.

Clinton: He wants to start it, he can start it. No, go ahead, Donald.

Trump: No, I'm a gentlemen, Hillary. Go ahead.

Cooper: Secretary Clinton.

Clinton: I think Donald was about to say he’s gonna solve it by repealing it and getting rid of the Affordable Care Act. And I'm going to fix it because I agree with you. Premiums have gotten too high, copays, deductibles, prescription drug costs and I have laid out a series of actions that we can take to try to get those costs down. But here's what I don't want people to forget when we’re talking about reigning in the cost that has to be the highest priority of the next president. When the affordable care act passed, it wasn't just that 20 million people got insurance who didn't have it before. But that, in and of itself is a good thing. I meet these people all the time and they tell me what a difference having that insurance meant to them and their families. But everybody else, the 170 million of us who get health insurance through our employers got big benefits. Number one, insurance companies can't deny you coverage because of a preexisting condition. Number two, no lifetime limits which is a big deal if you have serious health problems. Number three, women can't be charged more than men for our health insurance, which is the way it used to be before the affordable care act. Number four, if you are under 26 and your parents have a policy, you can be on that policy until the age of 26, something that didn't happen before. So I want very much to save what works and is good about the affordable care act. But we’ve got to get costs down, we’ve got to provide some additional help to small businesses so that they can afford to provide health insurance. But if we repeal it as Donald has proposed and start over again, all of those benefits I mentioned are lost to everybody. Not just people who get health insurance on the exchange. And then we would have to start all over again. Right now we are at 90% health insurance coverage. That's the highest we have ever been, in our country. I want to get to 100% and get cost down and quality up.

Cooper: Secretary Clinton, you are out of time. Mr. Trump, You have two minutes.

Trump: It is such a great question and it’s maybe the question I get almost, more than anything else. Outside of defense. Obamacare is a disaster. You know it, we all know it. It's going up at numbers that nobody’s ever seen, worldwide. It’s-nobody has ever seen numbers like this for health care. It's only getting worse. In 17, it implodes by itself. Their method of fixing it is to go back and ask Congress for more money. More, more money and we have right now almost $20 trillion in debt. Obamacare will never work. It’s very bad, very bad health insurance, far too expensive, and not only expensive for the person that has it, unbelievably expensive for our country. It’s going to be one of the biggest line items very shortly. We have to repeal it and replace it with something absolutely much less expensive. And something that works, where your plan can actually be tailored. We have to get rid of the lines around the state, artificial lines, where we stop insurance companies from coming in and competing because they wanted President Obama and whoever was working on it, they want to leave those lines because that gives the insurance companies, essentially monopolies. We want competition. You will have the finest health care plan there is. She wants to go to a single player plan which would be a disaster. Somewhat similar to Canada. If you ever noticed, the Canadians, when they need a big operation, when something happens, they come into the United States in many cases. Because their system is so slow, it's catastrophic in certain ways. But she wants to go to single payer, which means the government basically rules everything. Hillary Clinton has been after this for years. Obamacare was the first step, Obamacare is a total disaster and not only are your rates going up by numbers that nobody’s ever believed, but your deductibles are going up. So that unless you get hit by a truck, you will never be able to use it. It's a disastrous plan and it has to be repealed and replaced.

Cooper: Secretary Clinton, let me follow-up with you, your husband called Obamacare “the craziest thing in the world”, saying small business owners are getting killed, premiums doubled, coverage is cut in half. Was he mistaken or was his mistake simply telling the truth?

Clinton: No. I mean, he clarified what he meant and it’s very clear. Look, we are in a situation in our country where if we were to start all over again, we might come up with a different system. But we have an employer-based system: that’s where the vast majority of people get their health care. And the affordable care act is meant to try to fill the gap between people who are too poor and couldn’t put together any resources to afford healthcare, namely people on medicaid. Obviously, Medicare which is a single payer system which takes care of our elderly, and does a great job doing it, by the way, and then all the people who were employed, but people who were working but didn't have the money to afford insurance and didn’t have anybody, an employer or anybody else to help them. That was the slot that the Obamacare approach was to take. And like I say, 20 million people now have health insurance. So, if we rip it up and throw it away, what Donald is not telling you is we turn it back to the insurance companies the way it used to be. And that means that insurance companies get to do pretty much whatever they want including saying look, I'm sorry, you have diabetes, you had cancer—

Cooper: --Your time is up—

Clinton: --Your child had asthma, you may not be able to have insurance because you can't afford it. So let's fix what's broken about it, but let’s not throw it away and give it back to the insurance companies. That's not going to work.

Cooper: Mr. Trump, let me just follow-up—

Trump: I want to -- just one thing. Hillary, everything is broken about it. Everything. Number two, Bernie Sanders said Hillary Clinton has very bad judgment. This is a perfect example of it. Trying to save Obamacare—

Cooper: --Mr. Trump, you’ve said you want to end Obamacare, you’ve also said you want to make coverage accessible for people with preexisting conditions. How do you force insurance companies to do that if you are not mandating that everyone has insurance?

Trump: You’re going to have plans.

Cooper: What does that mean?

Trump: Well, I’ll tell you what it means. You’re gonna have plans that are so good because we’re going to have so much competition in the insurance industry, once we break out the lines and allow the competition to come.

Cooper: Are you going to have a mandate that Americans have to have health insurance?

Trump: Excuse me. President Obama by keeping those lines, the boundary lines around each state and it was almost done until just towards the end of the passage of Obamacare. Which by the way was a fraud. You know that. Because Jonathan Grouper, the architect of Obamacare was said, he said it was a great lie, it was a big lie. President Obama said you keep your doctor, keep your plan. The whole thing was a fraud and it doesn't work. But when we get rid of those lines, you have competition and we will be able to keep preexisting, we’ll also be able to help people that can't get, don't have money because we are going to have people protected. And Republicans feel this way. Believe it or not, we’re going to block grant into the states we’re going to block grant into medicaid so we will be able to take care of people without the necessary funds to cake care of themselves.

Cooper: Thank you Mr. Trump.

Sunday, October 9, 2016

What’s Cooking on Eve of Second Presidential Debate
If you pay close attention to what’s cooking in the eve of tonight’s presidential debate,  the consensus is clear.
Cooking of Trump Goose
What’s cooking is Donald Trump’s goose.   His vulgar tape of 11 years ago has finally done him in.  If not a cooked goose, he is definitely a dead duck, unfit to replace the present lame duck.  Trump, it is said, is sexual predator and dangerous demagogue posing as a presidential candidate.
So the media and the editorial boards of major newspapers,  including  the conservative Arizona Republican,  Dallas Morning News,  and The Wall Street Journal would have us believe.
They may be right, for once again the gaffe-prone Donald Trump is stewing in the juice of  his past, his temperament, and his character.
 Unfortunate Part of the Cooking Controversy
The unfortunate part of this boiling controversy is that  it  overshadows other salient issues.
Some 70 percent of Amerifcans, mostly living in fly-over-country between the Eastern and Western left coasts, think American is headed in the wrong direction.
These middle-of-the-country folk are concerned about these issues.

·         The tepid 2% growth of the American economy over the last 8 years.


·         The effective unemployment grate, if you include those who have stopped looking for jobs, of 10 percent/


·         The stagnation of  wages and savings.


·         The erosion of middle class cultural values in the wake of rampant secularism.


·         The decline of  American prestige and power on the world stage secondary to  globalism,   failed foreign policies, and the rise to terrorism.


·         The frustrations of the “silent majority” which as been drowned out by the vocal minority , especially in academia,  the press, and other strands of the liberal elite.
  • The "crazy" ObamaCare system, which Bill Clinton notes covers 25 million uninsured Americans while soaking millions more Americans with double digit premium and unaffordable deductibles while narrowing their choices of doctors and hospitals.
It’s enough to give you goose bumps about America’s future.   People are worried the present administration’s policies and their consequences have killed America’s golden goose.

Friday, October 7, 2016

ObamaCare Chaos
In Minnesota,  Oklahoma, and Tennessee,  three states in which I have lived or practiced,  ObamaCare premium rates are skyrocketing into the 50% to 67% range,  insurers are pulling out and citizens are losing plans and choices, and chaos reigns.
What does it all mean?   I was speaking to Dave Racer, a conservative publisher in Minnesota.  He says ObamaCare is unstable there, and major insurers are either increasing premiums,  capping enrollment,  or pulling out of health exchange markets.    He says if the Democratic Farmer Labor Market wins the next election there,   a universal coverage plan will be on the horizon within 18 months.
ObamaCare Alternatives
If ObamaCare health exchange markets fail, and ObamaCare goes down the tube, these options remain.
·         Universal single payer,  unlikely no matter who wins the presidency

·         A public option, if Clinton wins, with other fixes, such as ending  individual and employer options, moving the 55 to 65 crowd into Medicare, raising taxes for everyone. 

·         ObamaCare repeal, if Trump wins, with a market-based plan – competition across state line,  expansion of health saving accounts,  management of Medicaid by states – and God knows what else. 

·         Management of clinical medicine by machines and algorithms,  if progressively minded government experts have their way (Z, OBermeyer,M.D. and E.J. Emanuel , MD. of Harvard and Wharton (“Predicting the Future – Big Data, Machine Learning and Clinical Medicine, NEJM. September 29.”  

       Ekekial Emaneul Opinions
Ekekiel  Emanuel is one of the principle architects of ObamaCare.  He blames the Republicans for the health law’s problems and says with more government money poured into  “risk corridors,”  the health exchanges could be stabilized and insurer death spirals could be prevented,
Emanuel and co-author argue, that given time and money could solve complex clinical problems and “open up vast new possibilities in medicine.”  Machine learning will one, “dramatically improve the ability of professionals to establish a prognosis,” two,” displace much of the work of radiologists and anatomical pathologists,” three, “improve diagnostic accuracy.”
My Opinion
In my opinion, the health law’s travails result from the ACA being   passed without a single Republican vote, thereby triggering partisan opposition,  and from ignorance of the concept of insurance risk  by not allowing insurers to ask about pre-existing conditions.   
As far as “machine learning” goes,  I would point out that electronic medical records, have been a bust in the medical marketing space,  neither increasing efficiency, or improving quality in terms of diagnosis and prognosis.   I doubt that diagnostic  algorithms will significant displace radiologists or pathologists.   Data has a place as a supplement, but not as a replacement of these specialties.

Tuesday, October 4, 2016

Why ObamaCare Faces an Uncertain Future

With the presidential elections rapidly approaching, both candidates admit ObamaCare is in trouble due to public unpopularity,  heavy losses among insurers in health exchanges,   insurer withdrawals in multiple states leaving only one choice in 6 states, and soaring premiums (up to 67% in Minnesota.

Brief History of Modern Health Reform

In 1965, Congress passed the Medicare Act, which was quickly coupled  with Medicaid legislation.  That was the beginning of modern health reform.    The HMO Act of 1973  followed with DRG legislation close behind.   ObamaCare became law in 2010.   In 2016,  ObamaCare’s fate will be determined by the Presidential election, with Hillary Clinton promising to fix it and  Donald Trump pledging to repeal it.

ObamaCare Unraveling

With spikes of average premiums of 23% for individual health exchange markets  scheduled for 2017,   17 of 23 non-for-profit consumer-oriented plans collapsing,   and major insurers, including Blue Cross Blue Shield plans , withdrawing from health exchange markets,  ObamaCare may  be unraveling. 

This may happen no matter who wins the Presidency, even if the Obama administration pays $5 billion to 175 insurers  from the obscure Treasurer’s Judgment Fund to rescue “risk corridors” to satisfy legal claims against the government and to circumvent Republican opposition.

A Great Idea in Shambles

In the eyes of progressives,  ObamaCare remains  a great idea, a giant step forward towards universal coverage. 

What went wrong?   In a September 29 Health Care Blog,   “Fail to Scale: Why Great Ideas in Healthcare Don’t Thrive Everywhere.,” Jeff Goldsmith , a National Advisor to Navigant Healthcare,and Lawton Burns, a professor at Wharton,  put their finger on a central flaw in the law.  

No Single Bullet, Sweeping  Solutions Nationally

“A failure to understand and respect the role that local culture and market conditions for health system innovation profoundly limits the effectiveness of “single bullet” policy solutions….Perhaps a healthy respect for non-economic factors in health system behavior—often rooted in local and regional circumstances and in institutional culture—might be a corrective for those who see sweeping ‘national”’ solutions to complex problems.”

No Replicable, Expandable Regional Models

Policy makers and economists failed to recognize that there is no model for health reform that is replicable and expandable  to other sections of the country. What works in California (Kaiser’s top-down  integrated model with owned hospitals and physician employees),  may not work in the Midwest, South, or East( provider-led-organizations (IPAs) practices),  or  in the Southwest an , or with hospital dominated systems (Connecticut), or with academically-rooted large practices ( Harvard,  Johns Hopkins, Duke).

U.S.  A Pluralistic Populist Culture

The U.S. has a pluralistic, populist, polyglot health system.  Its citizens and its physicians cherish individual choice and privacy.  Physicians instinctively  reject condescending lectures from elites in Washington about what is morally right.   No single model works well in every region of the country.   It is political arrogance to think that centralized government can impose a single model or structure of care, e.g. Accountable Care Organizations, upon physicians or health care organizations. It is political ignorance that you remove all insurance risk by accepting all comers regardless of their pre-existing conditions or that you can pass a national health law without a single Republican vote.

Political and Social Forces at Work

Yet  the U.S. can no longer sustain rising costs of  health care  which will soon consume 20% of the national budget.

Political and social forces are at work in both the government and private sector in a search for solutions to rising costs and uneven quality.

ObamaCare has enrolled 8 million largely subsidized people its health exchanges and 5 million in Medicaid;  it has implemented data-based value systems to measure what it will pay doctors and hospitals; it has tried to expand Accountable Care Organizations; and it has forced physicians and hospitals to collect data through widespread use of electronic health records.   

Provider Reaction

The private sector has reacted with unprecedented hospital and medical group consolation, and with proliferation of urgent care centers, retail clinics,  direct pay concierge medicine,  and other outpatient centers and facilities.   

In the process, it has aggravated growing physician shortages,  and it has produced a system in which primary care physicians are being replaced or supplemented by physician extenders (physician assistants and nurse practitioners.

How Physicians Have Responded with Uncertainty : Physicians Foundation Survey

How have physicians responded to these sweeping changes? 

According to the just released 2014 Physicians Foundation national survey, which follows 2012 and 2008 surveys, the reaction has been mixed . 

The 2014 survey has over 17.000 responses to 650,000 questionnaires sent to practicing physicians. 

Of those who responded.

46% gave the ACA a grade or D or F, while 25% gave it an A or a B.


 81% said they were overextended or at full capacity, while  only 19% said they had time to see more patients.


50% would still recommend medicine as a career.


53% indicated they were employees of hospitals or medical groups, and only 17% were solo practice while 35% were in independent practice.


44% said they planned to take steps to reduce patient access,    24% did not take Medicare or limited it, and 38% did not see Medicare patients or limited their access.


33% participated in ObamaCare health exchanges, and 28% had no plans to do so.


They said they spend an average of 20% of their time on non-clinical paperwork.


85% had electronic health records,  46% said EMRs increased their efficiency, while 24% said it decreased their efficiency.


26% participated in Accountable Care Organizations but only 13% believed ACOs would enhance quality or  decrease costs.

Responses Not All Negative

Not all responses were negative. 44% said morale was up, an increase of 12% since 2012, and young physicians under 45 were more optimistic than their elders. 

A Changing of the Guard

Clearly there is a changing of the guard – from independent practice to hospital and large group  employment, from fee-from-service to data-based reimbursement,  from individual responsibility to measured accountability by government and corporate entities and employers.  


Wednesday, September 28, 2016

Three Trends I Missed in 2004
Twelve years ago,  I wrote a book  “The Doctor In America: Inside the Physician Culture.”  The book was never published.   At the time, I was editor of a newsletter Physician Options, was a contributor to,  and had just published a book A Managed Care Memoir,  an account of my personal journey through the highways and by ways of managed care across the U.S.
The book contained 19 chapters, containing commentary on the  physician culture and resistance to change,  new directions for 2005, improving Care in independent practice,   hospitals and physicians interactions ,  revitalizing primary care,physician  interaction with pharma, consumer driven care,  the power  Health Savings Accounts, and the question: “Can physicians adapt to consumerism and patient-centered care?”

In the new directions chapter,  I cited 8 trends.

1.        From a youthful society to an aging society obsessed with looking younger

2.      From inpatient to outpatient care

3.      From prescription drugs as an incidental expense to an intolerable cost burden

4.      From costs absorbed by employers to costs shifted to employees

5.      From national to world concerns about infectious disease

6.      From enough physicians and nurses to shortages of both

7.      From laissez faire medicine to activist programs to prevent and managed disease

8.     From a la carte care to standardized care ti improve quality, consistency, and outcomes

What I failed to see  were the massive movements to hospitalists,  to physician extenders,  and to ObamaCare.

·         Hospitalists -  From its inception in 1996,  the number of specialists called “hospitalists” has grown from a few hundred to 50,000.   The two physicians who first described  “hospitals,”  we have these words, “This new field is substandially larger than any suspeciality in internal medicine (the largest of which is cardiology with22,000 physicians, about the same size as pediatrics (55,000(, and in fact larger than any specialty except general internal medicine (109,000) and family medicine (107.000),  Apr9oximately 75% of U.S. hospitals… now have hospitalists).
  • Nurse as Physician Extenders  -   Thomas Bodenheimer MD and Laurie Bauer, RN, of the Cetner of Excellence in Primary Care (T.B.) and the School of Nursing (L.B.) at th University of California in San Francisco, make these predictions ( “ In the primary care practiced of the future, the physician’s role will increasingly be played by nurse practitioners (NPs).  In addition, the 150 million adults with one or more chronic conditions will receive some of their care from registered nurses (RNs) functioning as care manager.”  This is because of primary care shortages.  The number of primary care entrants is 8000, but the number of primary care physicians  retire each year will reach 8500 by 2020.

  • ObamaCare -   In 2004,  I failed to anticipate  that a national health reform law,  the Patient Protection and Affordable Care Act of March 2010, would be enacted, even though national pressures were building to protect patients against rising costs and medical bankruptcies.   Like everybody else I also failed to see the economic collapse of 2008, which made the election of President Obama inevitable.     We are now more than 6 years into ObamaCare, also commonly referred to as the ACA.   Although it has reduced the number of uninsured by 20 million and lowered the number of uninsured to just above 9%,  the ACA (Accountable Act) has been unpopular from the onset, largely because it has failed to live up to its promises of keeping your doctor and health plan and lowering premiums.   Instead millions of Americans have been forced to switch doctors and health plans, and their premiums have increased by $7500 rather than the promised $2500 reduction.      The fate of ObamaCare will be determined by the 2016 presidential election.